KINGSPORT, Tenn. — Republican Bill Lee and Democrat Karl Dean once again squared off Tuesday in the second of three gubernatorial debates. The latest head-to-head matchup, held in Kingsport, remained tame, with the party nominees joking about their birthdays while presenting their respective visions for the state.

Lee and Dean answered a host of questions on everything from health care and education to economic incentives.

Neither candidate threw punches

Dean and Lee have completely avoided pointed attacks on one another throughout the race, and Tuesday was no exception.

In fact, after mentioning it was his birthday, Lee used his opening remarks to thank Dean for his civility so far in the race, an apparent attempt to set the stage for a debate where no punches would be thrown.

"I am grateful for the tone of this campaign," Lee said. "It didn’t have to be that way.

"In spite of the fact that we have differences and we've had the opportunity to share our plans and our thoughts, as different as they may be, it's been an environment that the tone has been good and it has been positive."

The remark was fleeting but it set a tone for the debate and could have forced Dean to avoid taking any direct jabs at his opponent or risk looking like a bully.

Dean responded to Lee's comments with a birthday joke — a lighthearted jab for Lee, who is four years younger than Dean and has touted his lack of political and government experience as an asset.

"In recognition of the quality of this campaign, I am not going to, as Ronald Reagan would say, use your youth or inexperience against you in this race," Dean said.

Health care remains major dividing issue

Dean has made Medicaid expansion one of his primary talking points in the campaign, making the issue one of the most obvious differences in the two candidates' platforms.

While he reiterated his usual arguments — that expanding TennCare would cover an estimated 300,000 residents who don't currently qualify for Medicaid but can't afford insurance, and that the state is leaving billions in federal funding on the table each year — Dean pushed back on Lee's proposal more than usual.

Referencing an ad Lee released earlier in the day calling for "20-year solutions" to health care with "less government interference," Dean challenged Lee on what he would do to address the problem now and condemned Republicans in the legislature for offering no alternatives to Gov. Bill Haslam's 2015 Medicaid expansion proposal.

"This is a real issue that’s affecting real people in Tennessee right now," Dean said.

"What are they going to do to help health in Tennessee now?"

As Lee has previously said, he maintained that funds associated with expansion under the federal government are "not free money," suggesting that the state focus on finding ways to lower the cost of health care.

Dean faced pressure entering second debate

Going into Tuesday's debate, Dean was arguably under more pressure than Lee, given that the former mayor is down in all publicly released polls.

Although Dean pointed to two major differences with Lee — on Medicaid expansion and school vouchers — during the debate, he strayed away from pointing out other areas where the two have divergent views.

But afterward, Dean, speaking to reporters, said he didn’t have a chance to highlight such differences, including experience, arming teachers with guns, permitless carry and even a recent endorsement by a group of educators.

When he met with reporters, Lee took a different approach, saying he was pleased with the debate, calling it “great fun” while largely sticking to his key talking points on health care. Lee also pushed back against the notion that he would not address health care in the short term.

Although the head-to-head matchup once again left viewers to interpret who they believe owned the debate, Dean rejected the notion that he needed to have a high-drama moment to gain momentum in the race.

“I think what I need to do is show that I have the experience, that I understand these issues and that I can lead the state," Dean said. "I’m not trying to stage anything in these debates."

Reach Natalie Allison at nallison@tennessean.com. Follow her on Twitter at @natalie_allison. Reach Joel Ebert at jebert@tennessean.com or 615-772-1681 and on Twitter @joelebert29.